Acute vs. Precipitated Withdrawal
Withdrawal is syndrome that occurs after a person has built up a physical dependence on a psychoactive substance like alcohol, opioids, or benzodiazepines. Alcohol and drugs interact with the brain’s chemical messengers, disrupting their normal transmission, production, movement, and reabsorption within the central nervous system.
Neurotransmitters, such as dopamine, serotonin, gamma aminobutyric acid (GABA), and norepinephrine, are commonly affected. These neurotransmitters send signals in the brain that serve to regulate moods and emotions, learning and memory, motivation, and movement. Drugs like heroin and prescription painkillers interact with opioid receptors in the brain, and levels of dopamine are elevated as a result. High levels of dopamine create a euphoric rush, or “high.” When the drugs are not present, dopamine levels drop, and it can take some time for them to replenish naturally without the drug.
With repeated use of an opioid drug, it can become difficult for the brain to keep up with its natural production and transmission of the mood-regulating naturally occurring chemicals. The brain has now become dependent on drugs to keep it balanced. When drugs then process out of the body, withdrawal side effects begin.
Common withdrawal symptoms include:
- Muscle tension
- Stomach pain and cramps
- Joint, bone, and back pain
- Blurred vision
- Irregular heart rate and blood pressure
- Suicidal thoughts and actions
- Clenching teeth
- Mental confusion and trouble concentrating
- Memory lapses
- Breathing difficulties
- Dilated pupils
- Trouble feeling pleasure
Types of Withdrawal
The symptoms of withdrawal typically begin when the drug stops working (or being active) in the bloodstream. This depends on the type of drug and its particular half-life. In general, opioid withdrawal begins within 8-12 hours; benzodiazepine withdrawal in 12-24 hours; and alcohol withdrawal can start in as little as six hours after the last drink.
The bulk of the withdrawal side effects are usually contained and most intense during what is called acute withdrawal, which is when symptoms are the most significant. The type of drug abused, length of time abusing it, method of abuse, co-occurring disorders, environmental and biological aspects, and any polydrug abuse can all be factors in how long and serious acute withdrawal will be. The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes that acute opioid withdrawal typically lasts 4-10 days; acute alcohol withdrawal is generally 5-7 days; and acute benzodiazepine withdrawal is usually 1-4 weeks.
The National Institute on Drug Abuse (NIDA) reports that physical withdrawal symptoms typically let up after several days after stopping a drug that has been used long-term; however, emotional withdrawal symptoms may continue. This is called protracted withdrawal, and it may continue for a few weeks or months after acute withdrawal. It can include sleep difficulties, mood disturbances, and cognitive impairment.
Precipitated withdrawal occurs when an antagonist substance is introduced too soon after stopping an agonist drug. Antagonists block the effects of agonists (e.g., heroin, etc.). An agonist activates receptors in the brain while antagonists keep agonists from reaching them, thus rendering them ineffective. Antagonists, such as naloxone or naltrexone, can therefore be very helpful when attempting to reverse an overdose as they can flush out the agonist drugs and counteract their effects. They are also often used during addiction treatment and recovery to minimize relapse and promote treatment compliance.
When used too soon, as in before the agonist drug is fully out of the system, antagonist drugs can precipitate withdrawal. Precipitated withdrawal can be significant and have more have more intense side effects than acute withdrawal. It is like a speeded up and more serious version of acute withdrawal, and it can be life-threatening. Both acute and precipitated withdrawal are helped by medical detox, which can serve to manage the side effects and symptoms through medical support and care in a specialized facility under the watchful eye of highly trained professionals.
Dangers of Withdrawal and Preventing Precipitated Withdrawal
Withdrawal always has the potential to be dangerous and even fatal without proper care and attention. Central nervous system depressant drugs, such as opioids, alcohol, and benzodiazepines, all suppress vital life-sustaining functions like body temperature, heart rate, respiration, and blood pressure. When these drugs are used on a regular basis, the body and brain grow accustomed to their presence and disruption in the system. If they are stopped suddenly, or “cold turkey,” the autonomic functions of the central nervous system can rebound, causing a spike in heart rate, blood pressure, and body temperature. The body and brain are struggling to regain balance and may overcompensate without the presence of the dampening central nervous system depressant drug.
In addition to being physically troublesome and uncomfortable, acute withdrawal can also be emotionally difficult. Individuals may return to using drugs in order to self-medicate withdrawal symptoms.
In general it is common to relapse with addiction (rates are as high as 40-60 percent, NIDA reports), and it can be especially dangerous after a period of abstinence. A person may return to taking drugs at previous levels, and their body may not be able to handle it, resulting in overdose. The Centers for Disease Control and Prevention (CDC) warns that drug overdose fatalities are at an all-time high, as more than 50,000 Americans died from a drug overdose in 2015.
When withdrawal is managed properly, often through a medical detox program, drugs can be slowly tapered, or weaned off, over a period of time to mitigate withdrawal. In this way, acute withdrawal symptoms are more aptly managed. Typically, withdrawal symptoms crop up over a period of a few days, as the National Library of Medicine (NLM) reports that opioid withdrawal has both an early and late acute withdrawal phase. Early symptoms are uncomfortable and can gradually progress in intensity during the late phase. Withdrawal symptoms are managed with medications and supportive care as part of a medical detox program that provides around-the-clock treatment and supervision.
Buprenorphine and combination medications that often contain buprenorphine and naloxone are FDA-approved for the treatment of opioid addiction, as published by SAMHSA. Buprenorphine is a long-acting partial opioid agonist while naloxone is an antagonist. It is important to wait to administer buprenorphine or combination antagonist medications until after the initial agonist opioid, such as heroin or prescription pain relievers, has completely processed out of the body. Taking these medications too soon can result in precipitated withdrawal. Unlike acute withdrawal, the side effects of precipitated withdrawal can come on all at once and with great intensity. This can be extremely difficult and highly dangerous.
To prevent precipitated withdrawal, it is important for a person to be completely honest with treatment providers as to when the last dose of an agonist drug was and also to remain abstinent from these drugs during detox and treatment. Fortunately, the antagonist portion of combination medications (Suboxone, Zubsolv, Bunavail, etc.) remains dormant unless an individual alters the medication and then abuses it by injection. Use of these treatment medications in this way can precipitate withdrawal.
Both acute and precipitated withdrawal can be managed through medical detox.